Professional Documents
Culture Documents
Sustainable Healthcare Design
Sustainable Healthcare Design
Sustainable Healthcare Design
Sustainable
Healthcare Design
Sunand Prasad
Robin Guenther Richard J. Jackson
Phil Nedin Brendan Lovelock
Foreword
T
he primary arguments concerning the threat to the balance of the global
environment – through resource depletion, climate change and toxicity – are all
but settled. Scepticism must continue to be given space, after all it is at the core of
science; but without diverting attention from, let alone ignoring, the grave risks that have
become manifest. As US diplomat Pat Moynihan said, “Everyone is entitled to their own
opinions but not their own facts”. Unfortunately to date there has been more ignoring
than acting in response to the risks that science has identified and thoroughly validated
over the last 30 years. One reason for the lack of action may be that so often the issue of
sustainability, and in particular climate change, is framed in apocalyptic terms with ‘hair shirt’
attitudes – guilt, repentance, retributive justice – not far below the surface.
The diverse authors of the essays in this special supplement are united in their belief
that the world’s health services have a special role and responsibility in promoting action
to help restore the balance of the earth’s system; that they must take a lead in sustainability.
Moreover, we think of this as an exciting and uplifting journey to be embarking on, for the
systems thinking that it involves hold the prospect of wonderful co-benefits: for example
improvement in wellbeing and recovery linked to energy efficient connection of health
environments with nature.
My opening essay, Emergency Response (page 6), sets out the case for the special
connection between sustainability and health and goes on to deal with some specific current
concerns: how a focus on carbon need not compromise sustainability; how the challenge
in terms of the health real estate differs between developed and emergent economies;
and how behavioural change, involving everyone, is essential to creating sustainable change.
Healthy Places, Sustainable Spaces (page 10), by the public health and sustainability
expert Prof Richard Jackson, takes a broad view of the link between design, wellbeing and
the urban environment, by looking at the ways that our transport infrastructure has an
impact on health. He goes on to argue the case for changing the way health and design
professionals are trained to enable them make the creative interdisciplinary connections
that are going to be needed in the future.
Paying it Back (page 16), by architect Robin Guenther, argues that it is possible to
create hospitals that actively enhance the healthiness of humans as well as of the natural
environment, citing some exemplary facilities around the world that have taken the first
steps towards this inspiring goal.
The Long Game (page 22), by the engineer Phil Nedin, frames sustainability as five
oppositions in order to very clearly chart the choices that must confront the commissioners
of designs and buildings. This framework is a tool not only for understanding the issues but
for implementing sustainable practice in a knowing and inclusive way.
“The world’s health Intelligent Life (page 26), by information technology expert Brendan Lovelock, extends
the principle of sustainability to the domain of human resources and skills. He shows, for
services have a example, how rapid developments in digital and virtual technologies could be harnessed
special role and to improve the quality of the human experience of healthcare as well as the efficiency of
its processes.
responsibility in This supplement amounts to a plea to healthcare clients, experts, managers and
promoting action designers to show leadership in an area where it is now clear what has to be achieved and
many examples exist of how to start achieving it. The challenge of building a sustainable
to help restore future may seem daunting but we can be encouraged by the promise of an extraordinary
opportunity to take both the planet and ourselves to higher state of health and wellbeing.
the balance of the
earth’s system”
Sunand Prasad
Richard J. Jackson
An expert in the way that the built environment affects
our health, Richard J. Jackson is professor and chair of
Environmental Health Sciences at UCLA
Editorial Director
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Emergency
response
Sustainability may be a near-impossible term to define – but
healthcare and climate change are so strongly linked that health
services must play a huge role in reducing future carbon emissions
S
omeone once described sustainability philosophical sense but in practice it
as the slipperiest piece of soap in the requires us to be hyper alert to which part
shower. That may not be much help of which hymn sheet is being sung from
in defining sustainability but it does capture at any one time. For example, how do we
the erratic nature of its traction in public relate the current governmental emphasis
or corporate policy. As we approach the on carbon emission reduction to other
50th anniversary of Rachel Carson’s Silent resource issues? First, a summary of why all
Sunand Prasad Spring, the 40th of the Report of Club this is so pertinent to healthcare.
Senior partner, of Rome, The Limits to Growth, the 25th
of the Brundtland Report Our Common Sustainability and health services
Penoyre & Prasad Future, decisive action toward restoring the To most readers it will seem common
balance of the earth system fails to match sense for the world’s health services, like
the attendant rhetoric. These three seminal all other sectors of economies, to think
thought pieces successively brought to wide about sustainability and climate change
“Sustainability attention the high risks to the environment as an essential part of planning for the
and life of anthropogenic toxicity, resource future. Nevertheless it is worth rehearsing
remains an idealised depletion and climate change. why these imperatives must become a
destination that Brundtland said simply that development particular concern of health services.
was sustainable if it met today’s needs Firstly, global warming is already
is confusing our without compromising the ability of future impacting on the health of populations
collective sat-nav” generations to meet theirs. A simple and will increasingly do so. A UK NHS
proposition with unimaginably complex Confederation report in 2007 made the
consequences, sustainability remains an following assessment of the effects of the
idealised destination that is confusing our extreme weather we can expect1:
collective sat-nav.That would be bad enough
in the light of resource scarcity and the • more people will be hospitalised as a
toxification of the environment; but climate result of major emergencies
change turns a problem into an emergency • more frequent and severe heat waves,
with a very challenging timescale. which could result in an increase in
To add to the complexity the concept of heat-related deaths
sustainability has been stretched to cover • cases of skin cancer and cataracts are
the social and economic dimension too likely to increase by 5,000 and 2,000 per
which together with the environmental year respectively
calculus make up the ‘triple bottom line’. • cases of food poisoning could increase
Such a holistic approach makes perfect by 10,000 per year.
positively on all these. Opponents point to such that they aggregated to the required
the disastrous impact on world agriculture scores.That can and has led understandably
and forestry of the rush in the last 15 to designers gaming the system. The latest
“Rather than frame
years to manufacture biofuels, driven by version of BREEAM sets new thresholds climate change as
a crude focus on emissions reductions; or for energy and carbon that avoid these
the proliferation of useless domestic wind problems, promising to be a more effective a looming disaster,
turbines and ill-considered solar panels – so tool for advancing true sustainability. it seems far more
called ‘eco-bling’. However, the complexity of the systems,
This opposition seems rather pointless, requiring trained and accredited experts to creative to see it as
for there is a simple way of giving carbon its operate, is itself a barrier to practitioners an opportunity”
place while adhering to the core principles and clients focusing on the basic facts of
of sustainability. Carbon is indeed concern the environmental performance of their
numero uno and a good proxy for others, buildings: energy use (eg in kw hours per
but carbon mitigation must be achieved sqm per annum); net carbon emissions Despite unprecedented investment (about
in a sustainable way, which requires a (kg per sqm per annum); water use (litres £30bn) in the estate since 1997, the rate
close understanding of the long-term per day per person). Such figures need of growth in floor area has been around
consequences of every mitigation measure. to become everyday currency, like house 2.5% per annum4. That compares to about
The biofuels policy, especially that of the prices and construction costs, if we are 1% long-term average increase for the built
US Government, was unsustainable not to achieve rapid and transparent change. environment as a whole. Around 75% of
only environmentally, through potential loss We need to find a way of making every the UK’s built environment of 2050 is here
of forest, but also socially and economically architect and engineer, and hopefully many already, and barring another unlikely huge
through its damaging impact on food prices. clients, conscious of these basic metrics spurt in new build, that probably applies to
The danger of not focusing on carbon is, while deploying assessments systems as the health estate too.
if anything, greater. For over two decades an overall check, keeping them focused on New public buildings in the UK will be
we have had complex environmental things that really are measurable. required by 2019 to be low or zero carbon
assessment systems which attempt to but retrofitting existing buildings and
balance various sustainability imperatives to The existing health estate infrastructure is a far greater challenge. That
produce a single rating: BREEAM from the The health estates of western nations and challenge is not primarily technical: we know
UK, LEED from the US, the Australian Green those of the rest of the world, in particular how to optimise the efficiency of the existing
Star. Many other countries are bringing out the big emergent economies, pose very fabric, and, together with decarbonised
their own culturally tuned versions.Yet until different challenges. The former includes energy supply and behavioural change,
recently it was possible to score at the top a very large existing estate built almost achieve the emissions reductions required.
level in BREEAM and LEED with buildings entirely in times when fossil fuel energy was The problem is the billions of pounds
of relatively poor energy (and therefore virtually free, and there were no concerns of funding required, without financial
carbon) performance. Credits could be about emissions.The UK has 29 million sqm instruments in place comparable to those
accumulated for other virtuous measures of built estate, of which 21% is pre-19483. of new-build capital projects. Working with
existing buildings on ‘live’ hospital sites also
presents additional challenges, perceptions
of which can discourge health organisations
from undertake such projects.
In contrast to the west, China, for
example, will be building 2,000 brand new
county hospitals and 29,000 township
hospitals under its government’s healthcare
spending plans. Many of these hospitals will
be of 2,000-plus beds, much larger than
the trend in the west. Despite the plan, per
capita healthcare spending in China will be
$38 compared to more than $3,000 in the
US5 The implication is that this is only the
start of a hugely energy-hungry phase that
simultaneously presents the opportunity to
build for a post fossil fuel era and the threat
of failing to do so.The figures for India, Brazil,
the Russian federation and the Middle East
Figure 2: RTKL’s new 361,000sqm, 2,200-bed ‘mega hospital’ for Shanghai indicates an enormously energy- may be slightly less spectacular individually
hungry building phase for fast-growing countries such as China and India but, proportionate to their populations,
Healthy places,
sustainable spaces
Nothing makes a greater contribution to healthy lives than healthy
places. Public health experts need to collaborate with architects
and planners to address the real barriers to health and wellbeing.
I
served as director of the National Center would not list the real causes: poor urban
for Environmental Health at the United design, a lack of public transport and failed
States Centers for Disease Control and priorities of governance.
Prevention in Atlanta, Georgia, for nearly I realised that I and most of my colleagues
a decade. In that position I focused on in public health were not confronting the
large threats ranging from radiation to core purpose of our occupation: to assure
global warming, all the way to molecular the conditions where people can be
Richard J. Jackson threats such as chemicals that affect human healthy. There was scarcely anything more
Professor and Chair of endocrine systems. Each day, I drove to work important than the healthfulness of the
on the seven-lane Buford Highway, 50km environments in which people immerse
Environmental Health Sciences, of road lined with residential apartment their lives. I also understood that the health
University of California at buildings, many occupied by low-income problems we face in our built environment
Los Angeles, USA and immigrant families. The street has a cannot be fixed without going ‘upstream’, as
high volume of traffic, with few pedestrian we say. It is necessary to address the causes
crossings or pavements, and is infamously of disease and injury in order to prevent
unsafe: the number of injuries and fatalities them from occurring in the first place.
“By constructing along it is three times higher than any other This means that people not traditionally
places that are in the state of Georgia. One morning, I saw associated with health – architects, planners,
an elderly woman walking along the side traffic engineers and policymakers – need
inhospitable to of the road in a muddy trail worn into the to be engaged in the process.
people, we have weeds. Cars sped by as she slowly made her This fact led me to understand the need
way down the road, carrying a grocery bag for a new working paradigm that requires
compromised the in each hand. The sight of her walking alone those in the professions to move outside
health, prosperity along the most dangerous road in the state their comfort zones. Professionals must be
worried and saddened me, and I began to experts in their respective specialties, but in
and sustainability reflect on how I spend my time focusing the 21st century, they must cross domains
on remote threats, and not enough time much more in order to have genuine
of our society” on the ones that are immediate, especially impact. My own ability to effect change
to the poor. Along the roadway, there as a paediatrician and environmental
were neither trees providing shade from public health professional has been
the extreme Atlanta heat, nor benches to greatly enhanced by my work beyond the
give the woman respite. I thought: if she bounds of these specialties. Finally, these
were to collapse under the stress of the experiences have taught me that this work
summer heat, her death certificate would is inherently political: the fundamental
list ‘heat stroke’ as the cause of death. It determinants of health are often social
and economic in nature, and always involve compromised the health, prosperity and make vehicles and roads safer, and drivers
policy and politics in some way. sustainability of our society. more sober, have been effective in reducing
The experience of watching that Our health is determined in large part by the per-mile death rate nearly seven-fold
elderly woman opened my mind to new our environment (remarkably, even more in the US over the last 50 years, but one
possibilities, and helped spark a new field than our genes) – what we eat, drink and intervention has been inadequately applied,
of study on the health impacts of the built breathe, and where and how we live, work namely reducing the overall Vehicle Miles
environment. In the last decade, there has and socialise. The leading causes of death Travelled (VMT).
been a proliferation of research on the built in the US are cardiovascular disease and Vested interests assert that Americans
environment and health, as demonstrated cancer, sometimes referred to as ‘lifestyle’ love to drive, and this may certainly be
by a PubMed literature search of this diseases because they are, in part, caused true for uncrowded roads and highways,
term (see Figure 1, below)1. Ten major by unhealthy behaviours such as physical but those days are long past – in the US,
US universities offer concurrent graduate inactivity, poor diet and tobacco use. It two-thirds of the population are licensed
degree programmes in public health and is worth highlighting conditions in the drivers, and it has far more vehicles than
planning, and the number is growing. US because it appears as though other drivers. The most effective way to reduce
countries are following the same trends VMT is the provision of better public
Cars, planning and health of chronic disease. Remarkably, though, transport, but until recently there has
Increasingly, people in the US have realised unintentional injuries are the leading cause been long-standing resistance to public
that we have spent much of the last seven of death for Americans ages one to 44, and funding for this, and opposition to the use
decades designing our built environments injuries are the leading cause of years of of gasoline taxes for other than highways.
to prioritise automobiles rather than potential life lost for American males, and Also, the US has housing, mortgage, tax and
human beings. In a near-single-minded the second leading cause for females. The development traditions that impede the
pursuit to generate economic capital, majority of unintentional injuries are caused creation of the denser population centres
we have neglected to nourish social and by motor vehicle trauma. American drivers needed to support public transport. For
cultural capital. By constructing places have a one in a million chance of dying for example, despite the steep fiscal and
that are inhospitable to people, we have every 124km they drive. Interventions to environmental costs of single-passenger
auto travel and of air travel, there has been
great resistance in the US to creating high-
speed rail networks.
In Japan, the Shinkansen high speed rail
network has transported more than five
billion passengers since its inception, with
zero fatalities. In Europe, there are plans to
connect every major city by high-speed rail
in the next decade, for an estimated price
of €70 billion. That is a sum comparable
to what the US government spent to
bail out insurance giant AIG in the recent
economic crisis. In China, officials are keen
to invest in high-speed rail because they
see no sustainable future in clogged roads
and airways. The US lags behind, remaining
dependent on the petroleum industry even
as the sustainability, health and prosperity of
Figure 1: Twenty-year trend of the number of ‘built environment and health’ publications found on PubMed the country are compromised.
in five adolescents, are overweight or human capital. Nearly two years after the as a model for sustainable city planning
obese. In the last three decades, rates of start of the financial crisis, communities around the world. Many American cities,
overweight and obesity have tripled among throughout the US and around the world including New York, Portland, and Boulder,
12 to 19 year olds and quadrupled among continue to suffer its effects. have followed its example, and are lauded
6 to 11 year olds. Type 2 diabetes, once Europe offers examples of healthier as being the healthiest in the US.
called ‘adult onset diabetes’, is growing urban and community design. The built
increasingly common among US youth, due environment of many European cities The health-promoting hospital
in large part to rising rates of obesity. This promotes active transportation while The US can also learn important lessons
has staggering public health implications: maintaining cultural capital. Freiburg, from European healthcare facilities. Just as
developing diabetes before the age of Germany, is an exemplar of sustainable pharmacies ought not to sell tobacco and
40 shortens a person’s lifetime by 11 to community planning.The city has supported schools junk food, healthcare facilities should
14 years. Despite the fact that individuals active and public transport infrastructure not fail to be exemplary health-promotion
and the government expend enormous by making the city centre accessible to centres. In this century, no hospital should
amounts of money on medical care, if these pedestrians only, and by its investment be built without fundamental incorporation
trends continue, a decline in the American in bicycle road networks and parking, of good sustainability principles. Health
lifespan is inevitable. connectivity to public transport, and public- facilities must lead the movement in
The quality of life in America, too, transport-oriented development. Freiburg recognising that long-term population
has suffered in recent years. One in ten boasts over 400km of cycle paths and health and sustainability are inseparable.
American adults takes antidepressants, the 6,000 bicycle parking spots. In the last three Based upon the Ottawa Charter for
most commonly used prescription drugs decades, the share of trips made by bicycle Health Promotion, European health
in the US. Depression, anxiety and stress nearly doubled, from 15% to 27%, and the professionals and policymakers in the late
have undoubtedly grown in the wake of the streets are safer for it – Freiburg has 3.7 road 1980s developed the concept of health-
recent global economic crisis. Many families, fatalities per 100,000 residents, a rate that is promoting hospitals. A Health Promoting
civic institutions and communities bore the half that of Germany overall, and a quarter Hospital and Health Service (HPH) is “an
brunt of the recession, which was caused by that of the US. In spite of local population organisation that aims to improve health
the financial sector’s irresponsibility and the and economic growth in the last 30 gain for its stakeholders by developing
regulatory system’s negligence. Economic years, CO2 emissions from transportation structures, cultures, decisions and
capital has been allowed to supersede decreased during this time. Freiburg serves processes”5. In accordance with standards
“ substance,
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References
1. PubMed search terms ‘built environment’ and ‘health’. relationships with community design, physical activity, and and Health Services: Integrating health promotion into
[cited 9 October 2010]. time spent in cars. American Journal of Preventive Medicine hospitals and health services – Concept, framework and
2. Lachapelle U, Frank LD. Transit and health: mode 2004;27(2):87-96. organization. World Health Organization Regional Office
of transport, employer-sponsored public transit pass 4. Mokdad AH, Marks JS, Stroup DF, Gerberding JL. for Europe, Copenhagen 2007.
programs, and physical activity. Journal of Public Health Actual Causes of Death in the United States, 2000. JAMA 6. Standards for health promotion in hospitals. World
Policy 2009:S73-S94. 2004;291(10):1238-1245. Health Organization Regional Office for Europe,
3. Frank LD, Andresen MA, Schmid TL. Obesity 5. The International Network of Health Promoting Hospitals Copenhagen 2004.
Paying it back
The ultimate goal for hospitals is to turn one of the most
resource-hungry sectors of the built environment into one that
doesn’t just break even in its energy use, but actually generates
new resources
S
ustainability is now firmly rooted in that degenerates natural resources to one
the vocabulary of contemporary that restores or regenerates is akin to
healthcare design. Architect Stephen moving beyond doing ‘no harm’ to a built
Verderber, author of Innovations in Hospital environment that actually heals – a perfect
Architecture, states that “a hospital shall metaphor for the healthcare sector.
cause neither human nor ecological harm”
as a key tenet of innovative design thinking. The issues confronting healthcare
The launch of healthcare-specific green According to the American Medical
building tools is accelerating the adoption Association, US healthcare buildings
of a range of global, market-competitive consume 4% of annual national energy
green building strategies in healthcare and emit 8% of total carbon. But as the
Robin Guenther projects worldwide – countering the first decade of sustainable design draws
Principal, Perkins+Will, USA increase in resource intensity of the sector. to a close, it is increasingly clear that the
Globally, the best thinking in the green achievements in energy reduction are
building movement is moving beyond nowhere close to what will be required
conceiving of buildings as resource to produce the reduction in global
consumers toward the concept of greenhouse gas emissions required to avert
‘regenerative design’, where buildings significant climate change impacts. Average
“The healthcare are designed with inherent capability to modelled energy consumption reduction
become net resource generators rather in US LEED-certified healthcare buildings is
industry is just than resource consumers (see Figure 1, around 20%. The University of Washington
beginning to articulate below). Moving from a built environment Department of Architecture Integrated
Figure 1: Current thinking focuses on reducing resource depletion – ‘doing less harm’. As performance
improves, a net zero point is reached, beyond which resource generation begins, and the built environment
moves from ‘no harm’ to ‘healing’
health of the larger global community and and habitable – where notions of efficiency of potable water use for irrigation,
natural resources.” This in turn became have overwhelmed the quality of the patient long prioritised in LEED, is achieved by
the focus of the Green Guide for Health and staff experience and passive systems almost every certified healthcare project;
Care, a voluntary self-certification tool such as daylight and operable windows. total elimination of potable water for
that has informed both Greenstar for The enduring legacy of this thinking is the irrigation is increasing as projects begin
Healthcare and LEED for Healthcare. deep floor plan, devoid of daylight, that to capture rainwater and condensate
It has been eight years since the first characterises the contemporary North from air handling units (see Figure 2,
LEED certification of a US hospital. The US American hospital – totally uninhabitable previous page). Innovative wastewater
Green Building Council database includes without massive infusions of fossil treatment and use of non-potable water
more than 900 registered healthcare fuel energy. Energy demand reduction for sewage conveyance, on the other
projects, with more than 180 certified. continues to present challenges for deep hand, is slow to penetrate the US market
In 2010 alone, 106 healthcare projects plate hospital buildings designed with because of perceived infection control and
received certifications, more than the total variable air volume/reheat systems – regulatory concerns. In water-challenged
of all previous years. Despite the significant maximum energy demand reduction is regions, new hospitals may be separating
economic challenges of the last three years, approximately 18-20% as teams optimise plumbing risers to accommodate future
interest in and commitment to sustainable mechanical system technologies. In order non-potable water use in toilets, but
design continues to accelerate both in the to realise more significant energy savings, no hospital has yet operationalised this
US and globally. hospitals are installing either on-site strategy. The Oregon Health and Sciences
At the same time, innovative passive cogeneration plants or heat pump (ground University Center for Health and Healing,
and active system technologies, the or water source geo-exchange) systems, a free-standing ambulatory care facility in
reconsideration of deep floor plate resulting in energy demand reductions of Portland, Oregon, remains the only US
buildings and the use of reclaimed water around 40-50%. Displacement ventilation healthcare project to have included on-site
(even in drought-prone regions) continue systems, more commonly used in Europe, wastewater treatment and non-potable
to elude North American healthcare are beginning to be introduced in US sewage conveyance.
design. Particularly in the US, the healthcare hospitals based on emerging research and The demand for less-toxic materials
system faces the challenges of a regulatory regulatory acknowledgement. continues to accelerate. For example,
system based on technology mandates Hospitals are often among the largest The Green Guide for Health Care
rather than performance standards, potable water consumers in their includes credits relating to Persistent
despite the poor performance of health communities – unlike commercial office Bio-accumulative Toxic chemical (PBT)
infrastructure in weather events. buildings, however, close to 70% of potable reduction and phthalate avoidance; the
A focus on viewing healthcare water is consumed by process uses. For US Green Building Council is now piloting
environments as ‘machines for healing’ has many hospitals, the most significant single credits related to avoidance of PBT’s,
resulted in a generation of North American process use is cooling tower makeup water phthalate and flame-retardant chemicals.
hospital buildings that are less than humane in central energy plants. A 50% reduction The work of non-profits such as Health
Key:
1. Absorption chiller: utilises very hot water to
provide chilled water for cooling
2. High temperature anaerobic digester: for
bio-methane with conversion to pipeline-grade
natural gas. Also acts as sewage treatment plant
3. Solar hot water panel: provides hot water
for the absorption chiller and domestic use
4. Co-generation plant: generates electricity
with steam heated by natural gas from digester
5. Ground contact earth tubes: pre-cool and
dehumidify fresh air
5a. Dessicant dehumidification: touches up
fresh air after exiting earth tubes
6. Thermal chimney: pulls air though earth
tubes for delivery to mechanical system
7. Cisterns: for collection of rainwater, flushing
toilets as domestic water filtration system
8. Domestic water filtration system
9. Living roof area(s): pre-filtration for
rainwater heading to cisterns
10. Stormwater ponds: use water for irrigation
and as feedstock for domestic water filtration
system if cisterns run low
I
f we are to successfully deliver healthcare approach is more consistent with the right
to the planet’s six billion people, there hand side, the conclusion will be one of
are some important principles that we ‘business as usual’ and business sustainability
need to adopt: will not be strategically achieved. It is
important to note that although each
• healthcare is accepted as a priority for topic is independent, as we move
all and not a privilege for some through the framework there is a mutual
• healthcare must be a system beyond interdependence and an accumulated
political manipulation benefit. This is the added value gained by
• all must benefit but all must take their holistic thinking.
share of responsibility for their health
• healthcare provision is recognised as a Whole-life cost versus first cost
Phil Nedin, foundation of a successful economic and Almost all decisions are made on the
Global healthcare business democratic nation basis of cost but too often the only
• the costs of the provision of healthcare cost considered is the initial cost. The
leader, Arup, UK must be continually scrutinsed by those ongoing operational cost is usually part
who administer it and those who of another budget or in another portfolio.
benefit from it This separation often occurs in private
• the standards and quality of healthcare sector systems but always occurs in the
provision must be continually improved public sector. We must actively encourage
“Bed numbers in the as nations develop. bringing together the build and operational
acute environment costs in order to expand the opportunities
At first glance you may think that to provide real sustainable solutions. One
will need to be reduced, these principles are beyond the remit of example is the provision of new facilities at
the designers of healthcare systems and the expense of a number of older facilities
not increased. Rarely facilities. Nothing is further from the truth. being closed. If the holistic whole-life cost
in the briefing or design Designers have a significant part to play in benefit through the elimination of the older
the new world of healthcare provision. This facilities was always considered and placed
stage of a project does essay discusses a framework to illustrate above the initial cost, then we would have
this become a stated the influences that planners and designers some extremely strong business cases that
can bring to bear. would undoubtedly improve the provision
requirement” The framework (Figure 1, opposite) of our healthcare estate. The holistic view
consists of five continuums that test those would take into account the benefit of
who are involved with the provision of spatial flexibility together with the cost of
healthcare systems and facilities. Should the carbon emissions, maintenance, staff morale
approach by the team be consistent with etc. Unfortunately, in order to be successful
the left hand side of the model, then we with this approach we have to address two
can generally accept that the development areas of commercial discomfort. The first is
will be sustainable for the long term. the introduction of best value as opposed
However, should it be concluded that the to cheapest first cost and the second is
Intelligent life
Information technology can free hospitals and clinicians from
geographical restraints, and conserve an under-recognised
resource – skills. It’s time for designers to embrace its possibilities
S
ustainability is traditionally defined of healthcare facilities. However, building
in terms of the utilisation and automation and management systems
replenishment of a community’s are generally isolated from care and
natural resources. In this essay we extend operational management systems. This
this discussion to a human resource: the approach limits the capacity of a facility to
available healthcare personnel or, rather, optimise its operational environment in
the skills they provide. response to the clinical activity occurring
The way we develop the healthcare within it. This is wasteful of physical and
workforce to attend to a community’s natural resources and staff skills. Fortunately
needs and how their skills are applied (the there is a very promising emerging
‘model of care’) has a significant effect on trend: the integration of hospital building
Brendan Lovelock the design and operation of healthcare management and care management
Health practice lead, facilities. Unlike power, water and materials, systems with linked IT networks. This can
healthcare personnel not only provide a create intelligent environments, which are
Cisco Systems, Australia resource that allows a facility to function, ‘aware’ of the functions that occur within
they actively modulate how efficiently the them and can intelligently respond to
facility achieves its purpose. They are the patient needs and resource constraints.
main determinant of a healthcare facility’s
“The facilities we build outcomes and eco-efficiency. Skills as a limited resource
Models of care are undergoing profound As is the case with a number of renewable
now need to efficiently change. The introduction of clinical but constrained resources, the argument
use the clinical and information systems and the integration of for sustainable skills use is driven by the
patient biometrics (automated monitoring need to balance the social benefits against
operational skills that of patients), together with ubiquitous availability and cost. The healthcare skills
power them” collaboration technologies, mean that pool will be under intense pressure
the clinician is no longer bound to the over the next 40 years, with a significant
patient bedside for the delivery of care or increase in demand and a dwindling ability
to the same facility for consultation with to fund this increase.
peers. These fundamental changes impact As an example, the 2009 US national
hospital design.They enable a future where health expenditure is at $2.5 trillion (17.6%
the hospital is no longer constrained to a of GDP)1 rising to 19.6% of GDP by 2019.
given campus and care is not confined Overall, the OECD predictions show a
within its walls. Its function is not defined doubling of public spending worldwide
by the centralised geographic clustering on health and long-term care between
of facilities, but by the services that it 2004 and 20502. These trends are creating
coordinates and delivers throughout the enormous pressure to more efficiently
wider health system and the community. apply all our healthcare resources. At the
The evolution in patient care is mirrored same time as the cost of care is increasing
by a similar evolution in the management our ability to sustain this expenditure is
decreasing. The old-age dependency ratio “The healthcare skills pool will be under
(population aged 65+ in comparison to
working aged population) is predicted to intense pressure over the next 40 years,
increase from around 12% of population with a significant increase in demand”
in 2010 to 25% of population in 20503.
This shift is accompanied by a significant
reduction in family size3 impacting the
availability of volunteer carers. The impact
of these trends is often exacerbated in
rural and remote communities by the
concentration of clinicians in major cities.
These changes fuel intense debate
on how the community will provide an
acceptable level of healthcare over the well-established processes for the tasks occupied in professional communications
next 40 years. The effective use of our each care provider undertakes. However, with other clinicians. The equivalent
increasingly constrained healthcare skills the way individuals assemble into teams numbers for nurses show that 49% of their
resources is an important element of that and the way these teams interact within time is spent in information gathering and
discussion, and the facilities we build now themselves and with other teams in the communicating, with 20% of their time5
need to most efficiently use the clinical and hospital community is far more fluid – and spent in professional communications.
operational skills that power them. it is strongly modulated by their access to Given this high dependency on direct
information and their ability to collaborate. communications and clinical information
Skills utilisation When you look at the tasks undertaken access, the efficient use of team members
How we assemble our available skills into by a physician, 78.4%4 of their work skills is strongly dependent on the
the required models of care is an important concerns information gathering or information processes that have been
contributor of hospital efficiency. There are communicating, while 33% of their time is established within the facility.
Operational systems
The ability to free clinical data and face-
to-face interactions from their geographic
locations is developing alongside a third
dimension of the digital hospital IT design,
the automation and coordination of the
facilities’ operating systems. The patient’s
and clinician’s ability to interact with
the building in a way that optimises the Figure 4: Advanced telehealth facilities can now make the doctor feel like they are in the room with the patient
secure access to the hospital’s clinical Conclusion third dimension of IT impact is the ability to
information systems. Even the elevators Sustainable hospitals require not only the coordinate clinical skills with patient needs
can be prioritised for critical clinical events. efficient use of power, water and materials, and building operational systems. This will
All these applications run over a single but also of their clinical skills resources. enable the patient experience and resource
integrated IP network. There has been a dramatic transition of utilisation to be fully choreographed, and
It is not just the ability to manage these information systems in hospitals, where resource consumption to be optimised to
resources in isolation, but the increasing increasingly they have digitally enabled the desired quality of care output.
capability to choreograph all these resources their clinical data interactions. Access to Our emerging capability for remote
that is a new and exciting frontier in hospital information and decision-making tools has access to information and people,
design. This added level of control enables meant that data is virtualised – no longer integrated with a hospital’s operational
people-centred care to be designed into constrained to pages hanging at the foot of functions, allows the better use of our
the fabric of the building in a way that is a patient’s bed, but available to all who need increasingly scarce pool of healthcare skills.
aligned with the sustainable use of all the it. The next transition in health information Through better leveraging of this resource,
building’s resources. In these facilities, IT is occurring with the use of video and IT is now becoming a significant contributor
provides the intelligence to respond to collaboration technologies to virtualise to sustainable hospital design.
individual patient and staff needs. social interactions, so that clinicians can
gain access to care teams and patients, About the authors
Delivering the design independent of their physical location. This Brendan Lovelock is health practice lead for
The primary risk in delivering this vision in turn will enable new design options for Cisco Systems. This essay was co-authored
has two aspects. The first is the tendency hospitals, so that they can better leverage with Michael Boland, distinguished engineer
to consider IT later in the design process, the resources of their communities. The for Cisco Systems.
when the ability to influence design is low
and the cost of change is high19. Secondly,
there is a tendency to downsize the IT
plan as the project costs rise in the final “IT requires a higher priority in the early
stages the facility design, with the sentiment
that IT can be delivered at a later stage
design and final contract optimisation
in the project. However, this can lead to stages of a hospital build”
significantly higher total IT project costs
and sub-optimal facility performance.
Given its potential impact on the cost and
quality of care, information technology now
requires a higher priority in the early design
and final contract optimisation stages of a
hospital build.
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